Healthcare Provider Details

I. General information

NPI: 1306859608
Provider Name (Legal Business Name): DIANE T VALENTINE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N GRAND ST SUITE 2
GREENFIELD MO
65661-8198
US

IV. Provider business mailing address

1500 N OAKLAND AVE
BOLIVAR MO
65613
US

V. Phone/Fax

Practice location:
  • Phone: 417-637-5133
  • Fax: 417-637-5124
Mailing address:
  • Phone: 417-637-5133
  • Fax: 417-637-5124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN080891
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: